Severe reports

The report indicated that [Resident 3] contacted the Administrator, [Staff 2], and [Staff 2] directed [Staff 3] to take [Resident 1] to the emergency room for a "rape kit." The incident report further indicates that [Resident 2] and [Resident 3] were the alleged perpetrators of the assault. A review of the discharge paperwork from the hospital confirmed that [Resident 1] was evaluated for sexual assault and had contusions. In an interview over the telephone, [Staff 2] originally reported being unaware that there were any allegations of sexual or physical assault. [...] I need to speak to you asap because apparently a staff member sat and watch this happened and laugh... we really need the cameras." In an interview, [Staff 3] reported that [Staff 5] was the overnight behavioral health technician (BHT) and that [Resident 1] reported that [Staff 5] watched the assaults occur and did not intervene.

In an additional interview over the telephone, [Staff 2] reported never stating being unaware that there were any allegations of sexual or physical assault. [Staff 2] reported being aware only of the physical assault and not the sexual assault.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; R9-10-716.A.7.b. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

The nurse determined that Urgent Care or ER services were not needed and recommended that a PCP appointment be scheduled for further evaluation. [...] Shorty after, around 1450 the Member got up from [Resident 1's] seat and rushed towards [Resident 1's] peer and physically assaulted peer by throwing a barrage of punches to peer's torso and head.

From the state's report. Deficiency cited, complaint. Cited: R9-10-703.C.2.a. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A staff member and a child fought after the child struck the staff member. The staff member repeatedly slapped, kicked, and punched the child, leaving scratches and a welt on the child's face. Our summary of the state's report. The state's own wording follows.

The report stated, -"The nature and extent of the adult's vulnerability [in the alleged or suspected abuse, neglect or exploitation]: Suspected child abuse, consisting of staff slapped, kicked and punched client." -"The nature and extent of the adult's child injuries or physical neglect or of the exploitation of the adult's child property [include changes to the resident's physical, cognitive, functional, or emotional condition]: Client has scratches on arms and a welt mark across [Resident 1]'s face. [...] Staff then challenged the client, at which point the client lunged towards staff and struck [Staff 5] in the head. Staff raised [their], slapped the client and began punching [Resident 1] with a closed fist. [...] Staff eventually stopped; however, the client continued using profanity, kicked the staff, and pulled [Staff 5's] hair. Staff then became more aggressive by grabbing and hitting the client again.

[Staff 5] slaps [Resident 1] eight times and kicks them once (15:16:39-15:16:45).

[Staff 5] pushes [Resident 1], grabs and holds their arm, slaps them twice (15:14:45 to 15:14:48).

From the state's report. Deficiency cited, complaint and initial monitoring. Cited: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;; R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

The document stated, "...Staff informed...[Resident 1] attempted suicide by choking [Resident 1's] self with a shirt to the point [Resident 1] was unconscious [sic] staff immediately called 911. Staff explained that the incident occurred after [Resident 1's] peer was being moved to CRC...[Resident 1] became upset leading [Resident 1] to thoughts about when [Resident 1] would be going home...[Resident 1] went to [Resident 1's] room and shortly after [Resident 1] was found on the floor unconscious with a shirt tight around [Resident 1's] neck. [Police Department] was already on site because of another incident...[Resident 1] was transported to [hospital]...[Resident 1] moved to a higher level of care for now..." 2. [...] The document stated, "...Member attempted to self-harm using a bed sheet to choke [Resident 1's] self. [...] [Staff 7] reported [Staff 1] immediately called 911, removed the shirt, and checked to see if [Resident 1] was breathing. [Staff 7] reported EMS took [Resident 1] to [hospital] and [Resident 1] was transferred to a higher level of care.

From the state's report. Deficiency cited, complaint. Cited: R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Based on record review, documentation review and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicted a self-injury requiring immediate intervention by an emergency medical services provider. [...] 1. A review of [Resident 1]' s medical record revealed an incident report of a medical overdose by [Resident 1] on September 1, 2024. The report stated "At med pass, [Resident 1] was given [Resident 1] seroquel and [Resident 1] took the bottle, emptied it into [Resident 1] mouth, and swallowed 13 or 14 tablets." The report indicated [Staff 4] contacted 911 and poison control, and [Resident 1] was transported and admitted to the hospital. 2. A review of Department documentation revealed documentation to demonstrate BH7513 provided written notification to the Department of [Resident 1]'s self-injury was not available for review.

The assessment stated [Resident 1] is diagnosed with "bipolar disorder", had "3-4 attempts" of suicide, and had "tried to overdose with Benadryl." 4.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a ...; A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: Medical records showed one child went to the hospital after an injury and was put on meal lockouts and frequent checks. Another child was taken to the emergency room due to self-harm, and the state requested an internal investigation. Our summary of the state's report. The state's own wording follows.

Review of Patient #2's medical record revealed document titled "Unusual Incident/Injury Report" dated February 4, 2024, that revealed various details of the incident and transportation to a hospital via EMS following an assessment by an RN. [...] Staff has been aware of this...and pt was put on 30 minute lockout post meals and pt remains on q5 observation...." Review of Patient #1's medical record revealed "Therapeutic Intervention Note" dated January 11, 2024, that revealed "...Writer assisted BHT in transporting this client to ED...due to client's self harming...." A request was made for an internal investigation conducted by facility, per policies and procedures, for the incident with Patient #1.

From the state's report. Deficiency cited, complaint. Cited: R9-10-303. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health .... "[...]" marks text left out between sentences.

In plain words: A child in the program reported injuries after a physical restraint by multiple staff members. The child was sent to the emergency room for an evaluation and returned the next day. Our summary of the state's report. The state's own wording follows.

(Patient # 11) was sent to Valleywise ED for further evaluation as a precaution...." A review of a progress notes for Patient # 11 dated May 26, 2023 revealed "...Resident reported injuries sustained from his continued struggling against a code gray...restraint that required multiple staff to control him...guarding/pain at his left shoulder and elbow....He will be sent to the ER this evening for evaluation...." Employee # 1 confirmed in an interview on March 28, 2024, that Patient # 11 was sent to the emergency room for an evaluation on May 26, 2023 and returned on May 27, 2023.

From the state's report. Deficiency cited, complaint. Cited: R9-10-1302. Administration C. An administrator shall: 1. Ensure that policies and procedures are established, documented, and implemented that: t. Cover ....

The client was transported by EMS to the hospital; Individual's Condition Before & After the Incident: Physically fine before the incident but became upset during the incident. [Resident 1] was crying and in pain after the incident; Description of any Medical Services Received: EMS transported [Resident 1] to the hospital where [Resident 1] was treated for first degree burns to [Resident 1's] chest." 2. [...] 3. In an interview, [Staff 1] and [Staff 2] reported the first peer who threw water on [Resident 1] used hot water and the second peer used cold water, after [Staff 1] and [Staff 2] investigated the incident. [Staff 1] and [Staff 2] reported removing the peer who threw hot water from the facility and relocating the peer who threw cold water.

From the state's report. Deficiency cited, complaint. Cited: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: An administrator failed to notify the state in writing within one working day about a resident's death from a reported drug overdose. Our summary of the state's report. The state's own wording follows.

Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. [...] The e-mail from O1 was dated September 27, 2023 and stated "I received a call from Durango Detention and they informed me a medical examiner [O2] called them and they identified a youth that has an ankle monitor that has been deceased...I asked if [O3] knows what happen and [O3] stated early in the morning, a witness stated [Resident 1] was seen smoking a unknown substance at a QT off [street name] and [Resident 1] was taken to the emergency room where [Resident 1] died of a drug overdose..." 3. A review of Department documentation revealed the administrator failed to provide written notification to the Department of [Resident 1]'s death.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 1. Death, if the resident's death is required to be reported .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In turn, [Resident 1] became intoxicated and had to be transported to the local hospital for assessment. [...] 4. In an interview, [Staff 1] acknowledged, as a result, [Resident 1] ingested alcohol, which caused [Resident 1] to be under the influence, where [Resident 1] was transported to the hospital for a medical assessment.

From the state's report. Deficiency cited, complaint. Cited: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

The report stated [Resident 3] and [Resident 5] appeared to be "under the influence," as staff questioned [Resident 3] and [Resident 5], it was discovered [Resident 3] and [Resident 5] had ingested eight unprescribed Oxcarbazepine 600 mg capsules each, given to [Resident 3] and [Resident 5] by [Resident 2], who had taken the pills during assistance with the self-administration of medication, without staff noticing. Both [Resident 3] and [Resident 5] were transported to the nearest emergency room location in Maricopa.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.